The diagnosis presents many difficulties. It is exactly the sub continued bilious malarial fevers which often show, from a clinical point of view, no sharp separation from other similar diseases occurring in the tropics.
There is no doubt that errors in diagnosis are frequent, especially in India, which appears to be the breeding place of the different bilious infectious diseases. We need only recall the other forms of infectious icterus, Weil's disease, icterus gravis, acute yellow atrophy of the liver, to realize that the similarity of these conditions with a bilious malaria can be very close.
Fayrer states that confusion with yellow fever is especially likely when, in addition to the icterus, melena and hematemesis occur. Very severe cases of this kind were observed by Evers in Wardha (Nagpur district). They began with violent headache, epistaxis, hematemesis, melena, and high fever, and terminated quickly in icterus, subnormal temperature, coma, and death.
When the fever curve is not pathognomonic,-and it is this only in the rarest cases,-I believe that a rational diagnosis is assured only by the finding of the parasites. Yet this by no means asserts that the physicians in the tropics before the introduction of the microscope were not in a position to diagnosticate a bilious malaria . Familiarity with the disease picture obtained by daily observation gives a practical acquaintance that obviates many difficulties. Naturally such diagnoses would not be free from error.
The prognosis is dubious, both when the symptoms are only severe and when actually threatening (diminution of pulse tension). In general, the majority of cases recover on specific treatment. Algor, adynamia, coma, singultus, and anuria are unfavorable symptoms.
We take the following example of a gastrobilious remittent, associated with albuminuria, and followed by anasarca, from Kelsch and Kiener*:
H., artillery man, aged twenty five, has been three years in Algeria. Alcoholic. No previous disease. He passed the night between August 9 and 10, 1878, in the open air, exposed to a draft. When he awoke he experienced a pain in the back that prevented him from rising. He was put to bed, and during the course of the day suffered from severe chills and bilious vomiting
August 11 and 12: Continued fever, alternating with cold and hot sensations. Intense headache in the orbital region. Nightmare. After food or drink, vomiting. Admitted to the hospital at Bougie, August 13.
August 13: High fever, flushed face, pronounced weakness, nightmare. Tongue covered with a yellowish coat, nausea, occasionally bilious vomiting, epigastrium sensitive to pressure, two or three yellowish stools. No evident enlargement of the liver or spleen. Urine orange colored, clear, and shows, with nitric acid, a dark brown ring.
August 15: Fall of temperature without sweating. At 2 p.m.: A paroxysm of fever associated with chilliness.
From this time the fever preserved the quotidian intermittent type, its rises being accompanied by chilly sensations. During the remissions the skin was dry and red. The gastric disturbances improved somewhat; the diarrhea continued, and the urine showed hematin.
August 19: The patient took yesterday 1.20 cinchonidin sulph. The evening paroxysm was less marked. This morning, moderate fever. The flush on the face has disappeared and is replaced by an evident icterus. The urine shows the color of concentrated bouillon, is somewhat cloudy, clears up on heat, and shows, with nitric acid, a mahogany brown color, even more intense than before.
August 20: Apyrexia. The urine still contains hematin, yet less than previously. .
August 2.1: Urine of normal color, and shows, with nitric acid, a light brown color. The icterus begins to disappear; the appetite is increasing.
August 30: Edema of the legs, extending to the trunk. The urine contains considerable albumin, and shows again, with nitric acid, a brown color.
September 2: General anasarca.
September 5: Urine copious-three or four liters-and pale. Albuminuria slight. The anasarca is decreasing. October 1: Patient permitted to depart.
We take the following case of bilious pernicious, associated with adynamia, and ending fatally, from Laveran*:
G., sergeant. Came into the hospital at Constantine (the chief physician, Aron's ward), September 25, 1881. He asserts that he has been ill only four days. His work was at Bardo, a well known insalubrious locality.
The disease began with anorexia, general malaise, headache, and pain in the limbs. He had no chill and neither recently nor previously outspoken fever.
On September 25, the highest fever. Morning temperature in the axilla, 40°; evening, 39.2°. The sclerse and skin are intensely icteric. The patient answers questions directed to him, yet shows a pronounced inclination to torpor and adynamia. He says that he feels no pain. The tongue is red, dry, and fissured at the tip. Sordes occur on the teeth. The abdomen is yielding and painless. The right iliac region manifests no tenderness on pressure. The spleen is within the margin of the ribs. Pressure on the splenic and gastric region occasions no pain. The liver does not appear enlarged.
Febris biliosa malarica. Quin. sulph., 1.5; lemonade, calomel, 1.0, was ordered to be given on the morning of September 25.
September 26: Fever less high than yesterday; temperature: morning, 38.3°; evening, 38.5°. Yet this remission was not accompanied by an improvement in the general condition, but the contrary. The icterus is more marked than yesterday. Stupor and adynamia striking. Pulse, 80.
The voice is faint, husky, like in cholera. Tongue dry, fissured. Constipation. Abdomen painless. Quin. sulph., 1.0.
The patient vomited the quinin, and, in the course of the day, his condition became rapidlv worse. Deep adynamia, stupor, bilious vomiting, almost complete aphonia-1.0 quin. sulph. in clyster. Iced drinks, morphin, 0.04 in solution.
September 27: General condition worse. During the night, several times bilious vomiting. Subdelirium. Involuntary stools.